“全激光”内皮移植
Summary
An all laser procedure is proposed in the endothelial transplant. The surgical technique is based on the use of a femtosecond laser to prepare the donor tissue. Laser welding technique is then used to secure the donor endothelium in the correct position.
Abstract
The “all laser” assisted endothelial keratoplasty is a procedure that is performed with a femtosecond laser used to cut the donor tissue at an intended depth, and a near infrared diode laser to weld the corneal tissue. The proposed technique enables to reach the three main goals in endothelial keratoplasty: a precise control in the thickness of the donor tissue; its easy insertion in the recipient bed and a reduced risk of donor lenticule dislocation. The donor cornea thickness is measured in the surgery room with optical coherence tomography (OCT), in order to correctly design the donor tissue dimensions. A femtosecond laser is used to cut the donor cornea. The recipient eye is prepared by manual stripping of the descemetic membrane. The donor endothelium is inserted into a Busin-injector, the peripheral inner side is stained with a proper chromophore (a water solution of Indocyanine Green) and then it is pulled in the anterior chamber. The transplanted tissue is placed in the final and correct location and then diode laser welding is induced from outside the eyeball. The procedure has been performed on more than 15 patients evidencing an improvement in surgery performances, with a good recovery of visual acuity and a reduced donor lenticule dislocation event.
Introduction
在这项工作中，我们提出了一种原始的方法角膜内皮移植术的基础上，使用飞秒激光，以制备供体组织和近红外二极管激光器将其焊接到收件人床。供体角膜术测量要正确设计供体组织尺寸。角膜内皮移植术已经提出在最近几年，以取代穿透性角膜移植术治疗内皮疾病1,2。该技术的主要优点是视力恢复快，相对于外科手术，移植物排斥的风险降低和眼完整性的保存期间穿透性角膜移植术，减少麻醉。的主要危险因素是术后施主微透镜错位。的标准技术是通过将供体的内皮在其最终位置，它是由喷射的气泡的保持进行：无缝合的使用，因为在机械，生物物理和尺寸恰拉的内皮cteristics。此外，视力恢复可以供体和受体组织之间的不匹配的，主要是因为由于一个厚的组织移植的限制。
在这里，我们提出在执行角膜内皮移植术，可以克服这些主要问题的过程。施主内皮可通过使用激光焊接技术来保证在其最终位置。这是一个控制和局部光热过程：它可诱发在捐献者/接受者接口。据研究，在过去十年，在穿透性角膜移植术和血管内皮3-5的移植方案。近红外光（波长：810纳米）通过低功率二极管激光器射出被传递向在伤口部位的生物组织。角膜是自然透明的该波长：为了使此组织吸收的激光光，有必要用一个生色留下污点。所提出的染料是一种无菌饱和吲哚菁绿（ICG）D水溶液。我们表明，当角膜组织的正常沾上这个ICG制剂，它显示了在810纳米6的吸收峰。此外，ICG被广泛用于临床诊断和其安全性已被证实在人受试者。染色角膜吸收二极管激光能量和主要产生的效果是一种受控的温度上升在焊接部位。无热效应引起的未染色的组织。温度增强诱导所述基质胶原可逆的热变性，与伤口壁的冷却时立即closuring。这种激光焊接效果首先表现在白内障手术7,8和穿透性角膜移植9,10。我们展现本文优化的方法已经研究了在角膜内皮移植术的应用。
在建议手术治疗，单个激光点（持续几毫秒）ARê输送到组织，导致点尺寸（几百微米的直径）内的局部的光热效应：诱导效应是硬激光焊接，由密闭在捐献者/主机接口胶原的光凝。胶原变性在焊接现场的结果是供体和宿主组织之间有很强的粘合性，从而提供了一种缝合效果是不可能获得使用标准技术（针）。所述组织恢复他自然外观在很短的跟进（1个月）和供体/宿主组织之间的粘合力是通过在愈合阶段的非常早的阶段提供的焊接改善。
为了避免角膜内皮移植术的另一主风险， 即厚的供体组织的移植，intrasurgical光学相干断层扫描（OCT）用于：商用装置测量供体角膜的厚度，以使得正确的切割形状可设计成具有该femtosec激光。所提出的“全激光”内皮移植这样看来，以改善这种微创手术的临床效果。
Protocol
Representative Results
Discussion
“全激光”内皮移植是一种原始的方法微创角膜移植。
所有在协议中所描述的程序进行，在手术室内进行，观察卫生和消毒过程是在手术常见的做法，如用无菌手套，长袍，面罩和帽。 ICG的溶液的制备在手术室，前不久其在染色施主内皮应用。 ICG的粉末，水和所有用于制备染色溶液的工具是无菌的，并且可商购的用于在人受试者中的使用。激光光纤灭菌并它被安装在一特?…
Disclosures
The authors have nothing to disclose.
Acknowledgements
作者要感谢FORTE项目，由托斯卡纳大区（POR CREO FESR 2007-2013年，坂东的Unico R＆S 2012）资助，欧盟FP7 ECHORD ++的实验，部分支持的科研活动LA-玫瑰，和FP7 BiophotonicPlus工程“LITE”授托斯卡纳地区。
Materials
| Indocyanine Green | Pulsion Medical Systems, Germany | ICG-PULSION (http://www.pulsion.com/international-english/perfusion/icg-pulsion/) | Alternative product: IC-GREEN, Akorn Inc., Lake Forest, Illinois- US (http://www.icginjection.com/) |
| Femtosecond Laser | Abbott Medical Optics, Abbott Laboratories Inc. Abbott Park, Illinois, USA | iFS150 (http://www.abbottmedicaloptics.com/products/refractive/ilasik/ifs-advanced-femtosecond-laser) | |
| Optical Coherence Tomography (OCT) | Carl-Zeiss Meditec, Dublin, California- US (http://www.zeiss.com/meditec/en_de/home.html) | Visante | |
| Diode Laser | E.l.En. Group s.pa., Calenzano-FI, Italy (http://www.elengroup.com/en/divisions/medical) | Mod. WELD 800 | |
| Artificial Anterior Chamber | CORONET, corneal graft products. Network Medical Products Ltd. Coronet House, Kearsley Road, Ripon, North Yorkshire, HG4 2SG, UK | Artificial Anterior Chamber (A.A.C.) with large and small tissue-retaining heads. Code 51-935 (http://www.networkmedical.co.uk/ophthalmic_artificial_anterior_chamber.html) | |
| Solution for tissue preservation and nutrition | AL.CHI.MI.A. Srl, Viale Austria 14, 35020 – Ponte S. Nicolò – PD ITALY |
Carry-C media for corneal deturgescence and transport at room temperature – 12 x 50 ml (http://www.alchimiasrl.com/en/organ-culture-at-31°-c-eb/carry-c-eb) |
References
- Tan, D. T., Dart, J. K., Holland, E. J., Kinoshita, S. Corneal transplantation. Lancet. 379 (9827), 1749-1761 (2012).
- El Husseiny, M. A., Manero, F., Gris, O., Elies, D. Historical Review and Update of Surgical Treatment for Corneal Endothelial Diseases. Ophthalmol Ther. , (2014).
- Rossi, F., et al. Laser tissue welding in ophthalmic surgery. J Biophotonics. 1 (4), 331-342 (2008).
- Pini, R., et al. Combining femtosecond laser ablation and diode laser welding in lamellar and endothelial corneal transplants. Proc. SPIE Ophthalmic Technologies XVIII. 6 (844), 684411-1-684411-7 (2008).
- Rossi, F., et al. All-laser’ endothelial corneal transplant in human patients. Proc. SPIE Ophthalmic Technologies XXII. 8209, 82091O-1-82091O-3 (2012).
- Rossi, F., Pini, R., Menabuoni, L. Experimental and model analysis on the temperature dynamics during diode laser welding of the cornea. J Biomed Opt. 12 (1), 014031-1-014031-7 (2007).
- Menabuoni, L., et al. Laser-assisted corneal welding in cataract surgery: retrospective study. J Cataract Refract Surg. 33 (9), 1608-1612 (2007).
- Buzzonetti, L., et al. Laser Welding in Penetrating Keratoplasty and Cataract Surgery in Pediatric Patients. Early Results. J Cataract Refract Surg. 39 (12), 1829-1834 (2013).
- Menabuoni, L., et al. The ‘anvil’ profile in femtosecond laser-assistedpenetrating keratoplasty. Acta Ophthalmol. 91 (6), e494-e495 (2013).
- Canovetti, A., et al. Laser-assisted penetrating keratoplasty: one year’s results in patients, using a laser-welded “anvil”-profiled graft. Am J Ophthalmol. 158 (4), 664-670 (2014).
